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Potions and poisons

The dean of the nation’s top school of pharmacy on the challenges of treating patients. And a health care system.

The mother was alarmed. Her 6-year-old son had broken out in a rash, an unexpected and potentially dangerous reaction to cough medicine.

“Oh no,” she thought. “He must be allergic to ibuprofen.” The implications could affect her son for life: He might be unable to take one of the most common and effective medications for reducing fever, inflammation, and pain in young children.

She turned to a medical sleuth. He probed: Was it the first time the child had taken ibuprofen? Was it the first dose she had given from the bottle? Was the medication a combination therapy for cold and cough? Then: Did she thoroughly shake the bottle before each dose?

And with that final question, the mystery was solved: The reaction was probably not a response to ibuprofen. Instead, it was most likely an overdose of either the binder or the cold medication that had settled to the bottom of the bottle.

“Buy a new bottle, shake it well, and try again when you can watch your son carefully,’’ the mother was told.

Sleuth-in-chief

The sleuth was B. Joseph Guglielmo ’73, and for more than 30 years he’s been a leading clinical pharmacist, researcher, teacher, and administrator at the nation’s top-ranked school of pharmacy. Guglielmo, 61, is a nationally recognized expert on the use of drugs to control infection. Known as “Joe” to friends and colleagues, Guglielmo is a professor of clinical pharmacy at the University of California, San Francisco, and dean of the UCSF School of Pharmacy. He also oversees the California Poison Control System. The program, which fields nearly 900 calls a day, is the largest one in the country devoted to emergency phone advice for exposure to poisons.

In his highly collaborative work environment at UCSF, Guglielmo is often on the medical floor, making rounds alongside physicians and other clinical care providers, scrutinizing patient medication regimens, dispensing advice.

“All patients,’’ he says, are entitled to the “right dose of the right medication in the right route at the right time.”

He also says, “This is the best time to be a pharmacist.”

For decades, even centuries, pharmacists have been the medication experts, the chemists, and apothecaries who listened to a patient’s symptoms and mixed a drug specifically for them. In recent years, however, their role outside hospitals has been largely relegated to pill dispenser, with limited chances to provide expertise and insights directly to families.

At the same time, potions to treat illness have grown enormously in number and complexity, drug costs have soared, and health insurance has become unaffordable to millions. But with the country embarked on a new era of health reform, pharmacists are increasingly being recognized as a critically important component of health care. And Guglielmo is at the forefront of transforming that role to benefit patients and help reduce the cost of our health care system.

In December 2011, the U.S. Surgeon General issued a report calling upon health policy leaders to both recognize that role for pharmacists and pay them as health care providers. The report offers a controversial view in an era when insurance companies are trying to reduce costs—not pay for more providers—but is welcomed among the health researchers who have shown, time and again, the cost-value of including pharmacists in that role in integrated systems.

Greater participation of pharmacists in chronic disease management, particularly among community pharmacists, has long been Guglielmo’s vision.

In 2010, in an Archives of Internal Medicine commentary, he called for improved access to medical records, integration into care teams, and revisions in compensation allowing payment for medication therapy management rather than “prescriptions filled per day.” Such changes, he wrote, would expand access to health care and “unleash the full potential of these well-trained but clinically underused professionals.”

It’s complicated

In a small office inside UCSF’s Moffitt Hospital, a dozen infectious disease experts gather to discuss challenges posed by particularly complicated cases. They debate the treatment of an 18-month-old toddler who had developed strep-pneumonia and required dialysis (she fully recovered), a 58-year-old man with HIV, and a teenager with a baffling foot ailment as well as hearing loss.

In these sessions, Guglielmo collaborates with others on the medical teams to determine the best drug therapies, evaluating side effects, drug interactions, and possible outcomes.

One physician consults him about a patient who has become resistant to antibiotics. Another doctor asks Guglielmo’s advice about side effects under a proposed course of treatment.

“The dose you’d give him is exactly what he should be given,” says Guglielmo, drawing upon an uncanny ability to instantly recall a vast array of medical data.

A lot to learn

The mix: One day he’s doing a study
with a colleage in Zimbabwe, the next
he’s balancing the requirements of
serving as dean. “Every day is different,”
says Guglielmo. Photo by Majed

Born in San Rafael, Calif., Guglielmo grew up in the nearby community of San Anselmo. His mother, Patricia Tobener Guglielmo, died of Hodgkin’s lymphoma when he was five. He and his younger brother were raised by their father, Bernard Joseph Guglielmo Sr., a small-business contractor. His father later married a woman with four daughters—Joe, then 14, served as best man—and they had another child, Michael.

At Santa Clara, Guglielmo majored in biology. And he found the Mission Campus “a wonderful place to go to spread the wings.”

It was also at SCU that Guglielmo met Margaret Hedges ’75, a psychology major. “She was a much better student than I was—she was close to a 4.0,” he says. “I wasn’t anywhere near that.”

The couple married in 1975. Residents of Novato, they have four daughters and seven grandchildren.

Unsure of a career path after he graduated from SCU, Guglielmo took a year off and traveled, supporting himself as a waiter before venturing into medical sciences.

“I wasn’t driven to be a physician or a dentist, but I was intrigued by the work of pharmacists,” he says.

In 1978, he graduated from the University of Southern California with a doctor of pharmacy degree. He joined the UCSF School of Pharmacy in 1979.

He already knew he liked working in medicine in an academic environment. “And once I got into the clinical setting where I was touching patients and problem-solving, I blossomed.”

During his UCSF tenure, Guglielmo established a program to improve antimicrobial use and decrease microbial resistance to prescribed drugs.

“We are stewards of appropriate antibiotic use,” he says.

More than a dozen years ago, he was first offered the helm of the department of clinical pharmacy. He turned it down.

“I had daughters in high school,” he says. “I wanted to hear them play the saxophone and eat dinner with them. To me, it’s a big, complicated department—there was no way I would take it on.”

In 2006, he was persuaded to accept the post. “I learned what I already knew,” he says. Which was: “I had a lot to learn.”

Last year he took on responsibilities as interim dean for the entire School of Pharmacy. This spring he was named dean.

Potatoes and rice

For a quarter century, Guglielmo has mentored infectious disease specialty residents and fellows. In 2010, he was honored for his outstanding contributions to faculty mentorship with a lifetime achievement award. His research interests primarily center on the safe, effective, and appropriate use of antimicrobials, as well as the pharmacoepidemiology and pharmacokinetics of anti-infective agents. In lay terms, that involves looking at the role of anti-infective agents over broad human populations, and the action of anti-infective agents in the body over a period of time.

For many years, he has been the editor of Applied Therapeutics: The Clinical Use of Drugs and the Handbook for Applied Therapeutics.

“There’s no doubt I’m an academic clinician,” he says. “Every day is different. One day I’m doing a study with a Zimbabwean colleague to see if the African potato increases the metabolism of HIV medications.” Another day he’s balancing the requirements of serving as dean. “I’m really challenged by it … I don’t have to be the best teacher, but I enjoy teaching. I’m not the best clinician, but I enjoy treating patients. I’m not the best researcher, but I enjoy research.’’

Imperfection, he says, is fine with him—except when it comes to making risotto, his specialty in the kitchen.

“You never want to overcook the Arborio,” he says. “That’s a sin.”

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This story was updated on Oct. 30, 2013, to correct the number of grandchildren Joe Guglielmo has—from four to seven. “That's what happens when you have four daughters!” he says. —Ed.